Failure to Assess and Authorize Self-Administration of Medication
Penalty
Summary
A resident was observed with a Flonase nasal spray medication at their bedside without a physician's order, assessment, or care plan authorizing self-administration of the medication. The facility's policy requires that residents who wish to self-administer medications must be assessed by the interdisciplinary team, and if deemed appropriate, this must be documented in the resident's chart. Additionally, the policy states that residents should be instructed on proper administration and that medication storage must comply with state and federal requirements. In this case, none of these steps were followed for the resident in question. Medical record review showed that the resident had a BIMS score of 12, indicating moderately impaired cognition. During interviews, both an LVN and the DON confirmed that there was no physician's order for the Flonase, no order to self-administer, no self-administration assessment, and no care plan in place for the medication. The LVN also noted that the medication should not have been at the bedside due to the risk of access by other residents. These findings were verified through observation, interview, and review of facility policy and the resident's medical record.